Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

41. Right Inguinal Hernia with Osteitis Pubis…
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injury occurring usually as a result of chronic overload or impaction
trauma [ 7 ].
Osteitis pubis is also considered as noninfectious, inflammatory damage
to the pubic symphysis and its supporting structures [ 8 ] anatomically.
The pubic symphysis is mainly composed of fibrocartilage and is
a nonsynovial, nonvascular joint. The pubic symphysis is reliant on four
ligaments to maintain its supportive integrity. Most of the strength and
support arise from the superior and inferior ligaments, whereas the anterior
and posterior ligaments are of less supportive importance. The pelvic
floor musculature, composed of the levator ani and coccygeus,
inserts posteriorly at the pubic symphysis. The pectineus, rectus abdominis,
and oblique externus muscles, as well as the inguinal ligament,
insert near the superior portion of the pubic symphysis. The pubic rami
give rise to several muscle origins: adductor magnus, adductor longus,
adductor brevis, and gracilis. These muscles make up the adductors of
the hip [ 1 ].
The prevalence of osteitis pubis among the general population of
athletes ranges from 0.5 to 6.2 % [ 8 , 9 ]. Although many different sports
may be associated with osteitis pubis, sports with a higher risk include
soccer, football, ice hockey, and rugby [ 9 ].
The etiology of osteitis pubis is unknown; repetitive trauma alone or
in conjunction with opposing shearing forces across the pubic symphysis
is likely the main contributing factor in many athletes [ 10 , 11 ]. This
may be due to different types of movements, including rapid accelerationdeceleration,
kicking, and changes in direction.
Management
Nonoperative management of osteitis pubis is similar to that of other
causes of chronic groin pain and consists mainly of rest, ice or heat,
and nonsteroidal anti-inflammatory drugs (NSAIDs) or other oral medication
if patient can not take an anti-inflammatory medication. If these
initial modalities are not helpful after a defined trial period (3 weeks for
example), then the next intervention to consider would be glucocorticoid
injections directly into the pubic symphysis or oral glucocorticoids
[ 12 , 13 ]. Additional nonoperative interventions can then also
include physiotherapy focusing on core stability, muscle balance, and
rotational hip range of movement; and activity modification. The most
important lesson here is that if a patient has osteitis pubalgia and an
inguinal hernia, just repairing the hernia alone will not alleviate the